Take Two for November 13, 2012

Why is the US health care system so complicated?

David McNew/Getty Images

Nurse Allison Miller (L) checks the blood pressure of Keri Anderson as nurses and physicians give free basic health screenings and call attention to what they say is the ongoing healthcare emergency despite the decision of the U.S. Supreme Court to uphold the Affordable Care Act, on July 10, 2012 in Los Angeles, California.

If your job is to understand and analyze health insurance in America, getting care should be a snap. But that's not the case for Dahlia Remler.

She's a health economist and professor of public affairs at the City University of New York, but her struggle with her plan put her health and finances in jeopardy.

What was your health condition?
“My condition was something called Cushing’s disease, a little benign tumor in the pituitary gland, a very slow-moving disease, when I was diagnosed I probably had it at least 10 to 15 years. The only real cure to the disease is neurosurgery, they go through your nostril to take out this little benign tumor, it’s a very delicate surgery and it’s a very rare condition.”

What troubles did you have in choosing between two insurance plans?
“Couple of years earlier I had switched jobs and me and my husband both had to pick new plans, just months later his insurance premium spiked. He had to decide are we going to pay that much more money, even though it wasn’t open enrollment they would have let him switch to the HMO, the good insurers HMO but with no out of network benefits.

"We investigated the network, we asked people with all kind of conditions, and so we put him on this plan. As clues came in that I might have Cushing’s, I went to my endocrinologist, I said, 'Its open enrollment, I am so frustrated with my old insurer and dealing with their network, what do you think?' They said, 'Oh, we have this great new surgeon here who is specialized in the basal-cranial region,' which is right by the pituitary gland, so I checked that he was in the other plan, and I switched. A few weeks later the diagnoses was confirmed, I knew I needed neurosurgery, and what I discovered was that this spectacular neurosurgeon, who was in my network now, no one had ever heard of him as a pituitary surgeon.

"Honestly I was very lucky to discover that in network I could go to another city and get a well-known expert in my disease. So I didn’t have to make this agonizing trade off, you know, should I spend my own money out of pocket, to get this clearly unambiguous expert in this? I couldn’t figure it out because no one could tell me how to translate the surgeons reputation into how much better it was likely to be for me and my condition.”

If you get thrown for a loop how can we figure it out?
“Every one says if we have informed consumer shopping that will make for better quality products produced more cheaply and that will work for healthcare. And we all think that because for the overwhelming majority of stuff in the world it’s true. Choice may be valuable for other things but if you are thinking about how we are going to contain cost in our system, how are we going to deal with some of the quality failures, lack of coordination of care that we have in our system, counting on poor informed consumers, I mean this is hard and time consuming and takes a lot of effort. I’m a health economist. I had a slow moving condition, I had good insurance, we had money, I had a flexible job so I could investigate things in the middle of the day, I had job security, I mean I would be in sort of the ideal position and that is sort of the point, is we can’t just count on informed consumers.”

Confusion over what is covered is very common, Heather in Vanburren Arkansas is part of the Pubic Insight Network and tells her story:

"I became pregnant with my second child, and I did have insurance through my employer so went through the whole 9 months with midwife care and then afterwards, midwives usually charge a global fee of around $2,500 to $3,ooo, we were expecting to get our full $2,500 back but we got back maybe $700 or $800, and honestly I just finally gave up I was sick of messing with it, it had me in tears at times, I probably could have kept going and contacted an attorney but I just gave up," she said.

Heather had contacted her insurer just to make sure her midwife was fully covered. Is this an anomaly, Dahlia? Can you do your homework only to be told something else right after that?
“The problem is that it is so complicated there are all sorts of things I can think of that could be an issue. The problem is again I could have made a mistake listing them all. How is this woman supposed to find out about all the different things she could have asked for. She could have asked the midwife did you have experience with this insurer? Have you dealt with them before, this is my employer’s plan… but again even if she has experience with that insurer, her employer’s plan or her individual plan can be different, so you need to check for a lot of things and it is hard to know how to ask all of them.”

Everyone is waiting for the affordable care act to kick in; do you think it will make any difference?
“I think it is a step forward in some ways but on this no, for good reasons. You don’t want to change a system too much. This is a sixth of our economy, it’s a matter of life and death, and you don’t want to change everything at once so they didn’t. The kinds of problems that I had with understanding information will be pretty much the same in employer provided insurance but I hope that the people working on the exchanges will be aware of just how hard these things are, so they will work to simplify the choices and things like that.

How is your health today?
“My health is actually fantastic, Cushing’s disease is not easy to recover from but once I’m cured I’m fantastic, I have a ton of energy I am so much healthier it is really wonderful.”

Tell us your health care story. Become a source for KPCC journalists through our Public Insight Network.


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